“Sedation in the Office: Challenges for Pediatric Dentistry”

1. “Sedation in the Office:  Challenges for Pediatric Dentistry” Stephen Wilson DMD, MA, PhD Professor & Chief of Dentistry University of Colorado School of Dentistry and The Children’s Hospital

2. Pharmacological Issues Facing Pediatric Dentistry Today • The risks for the children involved with pharmacological management compared to routine communicative techniques, • Past safety record of pharmacological management, • Parental expectations and societal changes, • Nature of the child’s cognitive and emotional needs and personality, and • Extent of dental needs of the patient, • Monitoring, • Practitioner training and experience including the ability to “rescue” a child when significantly compromised, • Cost and third-party payors, • Venue issues (i.e., Office vs. Out-patient care facility)

3. Risks: Pharmacological vs. Behavioral Management • Pharmacological (sedation, general anesthesia) • Most significant adverse outcome: death • No direct data to support an estimated ratio of risk/benefit prior to and following published guidelines on sedation. • Fairly good estimate of number of deaths/morbidities in dentistry (invariably and indiscriminately lumping dental generalists and specialties together confounding interpretation), but no definitive data on the number of sedations actually attempted. Also, no summary data on how closely clinician followed guidelines. • For pediatric dentistry, the number of sedations actually attempted in an outpatient setting may approximate 100,000 - 200,000 per year based on survey data.* In extrapolating, it is estimated that over 1.5 million children have been sedated since 1985 when the first sedation guidelines appeared. • Behavioral (TSD, voice control, papoose board, distraction, coaxing) • Significant outcomes: bone fracture/dislocation of limbs; injury to face from bur • No data, but there are anecdotal reports.. *Houpt, M. (1989). "Report of project USAP: the use of sedative agents in pediatric dentistry." ASDC J Dent Child56(4): 302-9. *Houpt, M. I. (1993). "Project USAP--Part III: Practice by heavy users of sedation in pediatric dentistry." ASDC J Dent Child60(3): 183-5 *Houpt, M. (2002). "Project USAP 2000--use of sedative agents by pediatric dentists: a 15-year follow-up survey." Pediatr Dent24(4): 289-94.

4. Dental Needs Of Children • Dental caries is THE most frequent chronic childhood disease according to the US Surgeon General* • it is especially prominent in the underserved population (25% own 80% of caries problem) • 4 times more prominent than asthma • Program directors perceive that the number of new, recall and emergency patients and the number of pre-school aged children and children with special health care needs had increased in their programs over the last 5 years. • Payment by Medicaid was the most common insurance for children cared for in these settings. • The mean waiting time for scheduling treatment with GA for a child in pain is 28 days; without pain 71 days. The mean waiting time for scheduling treatment with sedation is 36 days.** * (2000). "Oral Health in America: A Report of the Surgeon General." U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health. ** Lewis, C. W. and A. J. Nowak (2002). "Stretching the safety net too far waiting times for dental treatment." Pediatr Dent24(1): 6-10.

5. Articles on Morbidity and Mortality Related to Dentistry

6. Practitioner Training • Current accreditation standard indicates that • a minimum of 1 month of anesthesia experience is required (oral and maxillofacial surgery standards require a minimum of 4 months); • CPR required (and many programs require PALS or ACLS); and • sedation experiences (number, routes, types not specified). • Overwhelmingly, sedation in training programs involve oral and rarely, intravenous sedation. Probably no other specialty has as much clinical experience in oral sedation than pediatric dentistry. • Today, most state boards of dentistry require a sedation permit (facilities site visit, PALS or ACLS certification, sedation training). • Currently, AAPD leadership is pursuing “standardization” of training to include standardized didactics and clinical sedation experiences amongst all accredited pediatric dentistry programs; one of the principles involved would be incorporation of “rescue” training.

7. Parental Expectations and Societal Changes • How I was trained (almost 25 years ago): • No parent allowed in operatory unless child is < 3 years of age • Hand-Over-Mouth (HOM) w/wo airway restriction (99% successful and took < 30 seconds to accomplish – at no financial obligation and no documented adverse effects – BUT was abused and a priori consent not obtained) • 25-75 GA cases/year; @ 100 sedations • Today’s world – Board-certified pediatric dentists* • A majority perceived parenting styles had changed for the worse during their practice lifetime • 92% felt changes were "probably or definitely bad“ • 85% felt that these changes had resulted in "somewhat or much worse" child patient behavior • More crying & struggling • Less cooperative • Parents are primary cause because they fail to set limits on their children’s activities • Practitioners report performing less assertive behavior management techniques than in the past due to these changes. * Casamassimo, P. S., Wilson S., Gross, Ll. (2002). "Effects of changing U.S. parenting styles on dental practice: perceptions of diplomates of the American Board of Pediatric Dentistry presented to the College of Diplomates of the American Board of Pediatric Dentistry 16th Annual Session, Atlanta, Ga, Saturday, May 26, 2001." Pediatr Dent24(1): 18-22.

8. Office Accountability • Most of dentistry is a cottage industry with regulation by state dental practice act. Each practitioner, once licensed, is responsible for patient safety in his/her own practice. • Most states require practitioners who do sedation to have a permit to do so. Usually this requires a site visit from a consultant responsible to the state dental board. The visit usually involves examination of the facilities in terms of meeting sedation guidelines, practitioner training (i.e., PALS and educational/clinical training), emergency management protocol, and paperwork. Yet, there is considerable variability among state dental practice acts. • If emergency occurs, the practitioner must be prepared to manage the patient until assistance (EMS) arrives. This issue may be most important challenge for our specialty for those who sedate in the office.

9. Sedation in Pediatric Dentistry • Most regimens involve either a benzodiazepene alone or a combination of agents. • Most popular benzo is midazolam given primarily orally (0.5 – 1.0 mg/kg) • Common agents used in various combinations include chloral hydrate, meperidine, antihistamines, and benzos.

10. Common Drug Combinations

11. Key Factors In Drug Selection & Dose • Child temperament & personality • Clinical assessment • query parent(s) • observation with parent • observation with parent & assistant • Clinical classification • easy • slow to warm up • difficult • Type and duration of dental care • ultra-short extraction of maxillary incisors • short quadrant of dentistry • long 2 or more quadrants of dentistry

12. Scheme For Selecting Agents

13. Current AAPD Sedation Guidelines • 5 functional levels of sedation • I - anxiolysis • II - interactive • III - non-interactive, arousable with mild/moderate stimuli • IV - non-interactive, arousable with intense stimuli • V - GA

14. Responsiveness

15. Personnel & Monitoring Equipment

17. Number of Publications in Pediatric Dentistry: Involving “Sedation”, “Dentistry” and “Pediatric” Topic (related) Number of Pubs Chloral hydrate 29 Midazolam 21 Meperidine 17 Diazepam 7 Triazolam 1 Morphine 1 Monitoring 20 Blood Pressure 6 Pulse Ox 6 Capnography 7

18. Research Needs • Systematic, prospective studies investigating patient personality, drug selection/dosage, duration and type of care delivered. • Relationship among peri-operative factors and patient safety including fasting, drug dose, and recovery. • Cost analysis of sedation in terms of supplies, personnel, risk/benefit. • Educational settings, training standards, and outcomes assessment related to patient safety and professional responsibility. • Investigation and implementation of repository of cases categorized in terms of protocol variables and outcomes of sedation cases.

19. Educational Needs • Standardized training possibly involving regional centers of educational excellence. • Multidisciplinary exchange of information aimed at educating professionals outside of one’s discipline/specialty that will benefit patient care and minimize misunderstanding.

20. Questions???